Download Please use this form only to refer clients to Safe Haven Sussex CIC.

Safe Haven Sussex CIC
Confidential Client Referral Form
Safe Haven Sussex CIC provides supported accommodation to people with care support
and supervision needs. Dependent on individual circumstances clients can be supported
in supervisory community based shared properties.
Please use this form only to refer clients to Safe Haven Sussex CIC.
Guidance and information:
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Please type or write clearly and preferably in black ink
Please give clear information about the client
Add any additional information to the referral form
We aim to respond within 48 hours
Please email forms to the address below
Safe Haven Sussex CIC
Telephone: 01273 757070
Email: [email protected]
Name of Referrer:
Position:
Name of Organisation and address:
Telephone:
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Client Referral form/revised July 2017/AC
Safe Haven Sussex CIC Client Referral Form
Section One: Personal
Name of Client:
Date of birth:
Nationality:
Ethnic origin:
Religion:
Present Home Address:
Telephone:
Previous location:
National Insurance Number:
Benefits received (please note clients must be in receipt of a benefit other
than housing benefit to be eligible):
Has client been assigned a Social Worker or Community Psychiatric
Nurse?
If applicable please give details:
Section Two: Next of Kin contact details
Name:
Relationship:
Address:
Telephone:
Mobile:
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Client Referral form/revised July 2017/AC
Section Three: Medical and Psychiatric detail
Diagnosis: Please be as specific as possible
Existing Related Symptoms: Please give details
Mental Health Section (if applicable) Has the client been diagnosed with a
mental health condition?
Has the client had a mental health assessment, if yes please provide
details
Medication currently prescribed: Please give full details
Section Four: Drugs/Alcohol Use
Please give full details:
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Client Referral form/revised July 2017/AC
Section Five: Behavioural Issues:
Please give as much detail as possible:
Section Six: Criminal Offences:
Please give details:
Offence:
Custodial Where was the
Sentence Sentence served?
Yes No
Length of sentence:
Dates:
Section Seven: Support Needs
In the referrer’s opinion what care, support or supervision requirements
does the client have?
Does the client have social interaction issues? (please give details)
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Client Referral form/revised July 2017/AC
Describe any problems encountered by the Client with daily living
activities:
E.g. cooking, cleaning, taking medication, going out, using public
transport, laundry, shopping, budgeting, personal hygiene.
Section Eight: Risks to be noted:
Please give details of any risks that need to be taken into consideration:
Section Nine: Bank details:
Bank/Building Society/Post office Name:
Savings:
Which bank account?
How much?
Section Ten: Relevant documents attached to this form:
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Client Referral form/revised July 2017/AC